1-21 UPDATE IN INFECTIOUS DISEASE Annals Int. Med. January 1, 1997; 126: 48-56

Infectious diseases is a rapidly moving field largely because of advances against the human immunodeficiency virus. However, the situation in other, more traditional, areas of infectious diseases is more worrisome, especially given the emergence of new viral diseases and the growing antibiotic resistance of older, more common bacteria.

1. Trends in Infectious Diseases Mortality in the United States JAMA 1996; 275:189-93

Deaths from infection are on the upswing. Over the past 13 years the death rate for persons aged 25-44 increased 6-fold, primarily due to HIV infection. The rate of death from infections increased 25% for persons over age 65, and the rate of death from septicemia almost doubled. To keep things in perspective, nearly half of the deaths from infection in the United States were caused by respiratory infections, most of which were in persons older than 65 years of age, and most were categorized as caused by pneumonia of unspecified etiology.

2. Measles Elimination in The Americas: Evolving Strategies JAMA 1996;275: 224-29

Regional measles elimination is possible, a finding that may set the stage for eventual global elimination of measles.

3. The Effectiveness of Vaccination Against Influenza in Healthy, Working Adults. NEJM 1995; 333: 889-93

Persons who received vaccine reported 35% fewer upper respiratory infections. 43% fewer days of sick leave, and 44% fewer visits to physicians for respiratory illnesses. Flu vaccine is cost-saving.

4. Outcome of Multi Drug Resistant-TB Patients 1983-93, Prolonged Survival With Appropriate Therapy Am. J. Resp. Crit Care Med. 1996; 153: 317-29

Multidrug resistant TB is defined as resistance to isoniazid and rifampin, the 2 best drugs. A new strain (strain W), occurring mainly in New York City, is resistant to at least 6 agents. Most multidrug-resistant strains are seen in HIV-infected patients. Treatment resulted in an overall survival of 61% with a median duration of survival of over 10 years. For patients with AIDS median survival was 7 months. The diagnosis of TB is commonly delayed. The guidelines of The American Thoracic Society and the CDC, which advocate an initial 4-drug regimen, would have led to inadequate initial treatment in 34% of these patients.

To improve prognosis: (1) early detection; (2) directly observed therapy, (3) avoiding clustering of patients with AIDS in hospitals.

5. The Prevalence of Drug-resistant Streptococcus Pneumoniae in Atlanta NEJM 1995; 333: 481-86.

This study reported a 25% rate of resistance to penicillin; 26% to trimethoprim-sulfamethoxazole; 1 to erythromycin; 9% to cefotaxime; 8% to tetracycline; 6% to imipenem. Because of resistance to so many antibiotics, it is becoming increasingly difficult to recommend agents for empirical treatment of pneumonia, otitis, and sinusitis. The current recommendation for pneumococcal meningitis is vancomycin plus cefotaxime or ceftriaxone. The recommendations now almost universally accepted are reduction in unnecessary use of antibiotics and broader use of pneumococcal vaccine. The vaccine includes the serotypes that represent 89% of the isolates associated with resistance.

6. HIV A number of articles concerning HIV infection and AIDS are also included in the update. See text for citations.

1. HIV replicates and mutates rapidly. This leads to the advice to hit early and hit hard.
2. RNA replaced CD4+ cells as the superior marker.
3. Risk after needle stick is stratified. Prophylaxis with zidovudine and lamivudine (and indinavir for subjects with high risk injuries) is recommended.
4. Kaposi sarcoma is caused by human herpes virus 8.
5. Guidelines for treatment of opportunistic infections is presented (table 5 p. 54).
6. Resistance to protease inhibitors may emerge.
7. Number of AIDS cases in the US exceeds one half million. (21 million worldwide).
8. Primary care physicians commonly missed common signs of HIV infection-Kaposi sarcoma, hairy leukoplakia, and diffuse lymphadenopathy.

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